Analysis Safe Speed/Action to avoid Collision The SpiritofVancouverIsland was both accelerating and altering course throughout the short period of time after her departure and until collision. As the vessel was not on the MCTS radar screen, no tracks were plotted. Consequently, it is not possible to accurately establish her speed at any point in time. The bridge log of the SpiritofVancouverIsland records 1105 as the time of departure and 1111 as the time of collision. Victoria MCTS logs indicate 1106:45 as the time the ferry communicated its departure on VHF and 1110:30 as the time a pleasure craft called to report the collision. Over a distance of 6.2cables (1148m), the MCTS times indicate that 3minutes and 45seconds elapsed between the time the ferry got underway and the time of collision. These figures result in an average speed over the ground of 9.9knots. However, the vessel had been accelerating since departing from her berth and the maximum pitch for speed control setting No6 was achieved at 1107:36, almost 3minutes prior to the collision. This would indicate that the vessel was travelling at a speed greater than 9.9knots and had, in fact, achieved a velocity approaching 13knots. The effect of the current setting in an ESE'ly direction at less than a knot would have been negligible. Analysis of MCTS data and comparative data from previous sailings agree with a speed of approximately 13knots at the time of the occurrence. Good seamanship practices dictate that speed be adjusted such that a vessel can be stopped within a distance appropriate to the prevailing circumstances, taking into consideration the manoeuverability of the vessels involved.4 Soon after departure, the SpiritofVancouverIsland increased to a speed greater than that of the StarRuby. This culminated in the ferry overtaking the StarRuby in the narrow and shallow 460m long section of the buoyed channel. In so doing, the ferry's ability to take proper and effective collision-avoidance action was first reduced and then eliminated. Risk of Collision Prior to the ferry's departure, the bridge team brought to the attention of the master three pleasure craft that could interfere with the ferry's passage. Once underway, the master elected to increase to his customary speed and overtake the pleasure craft, sounding two blasts to indicate a port course alteration. The master's primary concern then became the navigation of his vessel to the detriment of collision avoidance. While conducting the SpiritofVancouverIsland toward the buoyed channel, the master's attention became focussed on the parallel index lines of the radar in order to keep his vessel in that portion of the channel that would provide adequate draught for his vessel. The master did not use to advantage the traffic information he received from the bridge team. As the distance between the ferry and the pleasure craft decreased, warning signals were sounded on the ferry's whistle which resulted in two of the pleasure craft taking action and moving away from the path of the ferry; the StarRuby did not. Consequently, by the time the ferry's master initiated emergency measures, it was too late to avert collision with the StarRuby. At departure, with the StarRuby approximately 50 on the ferry's starboard bow, at an approximate range of 4-5cables (740-925 m), the ensuing actions of both vessels resulted in the range closing, and although no compass bearings were being taken, relative bearings sighted by components of the ship's structure indicated a risk of collision. It is clear, therefore, that neither vessel used all available means to determine/evaluate the risk of collision. Lookout Maintaining a proper lookout is essential for situation appraisal, warning of risk of collision and preventing collisions. A lookout must be maintained by sight and sound and utilize all available and appropriate means - which could include radar and radio.5 SpiritofVancouverIsland All members of the bridge team had sighted and were aware of the presence of pleasure craft in Colburne Passage, including the StarRuby, in advance of departure. Due to the difficulty in identifying individual pleasure craft by name and establishing VHF communications, passing arrangements are normally not made with pleasure craft over the radio; VHF R/T was not used by the ferry personnel to arrange a safe passage. StarRuby As there was no survivor, and given the impact of the collision, the status of the operator's visual acuity and/or hearing aid at the time of the accident could not be established; nor was it possible to establish whether the operator's guest had heard the sound signals. Hence, the reason for StarRuby not responding to the ferry's sound signals could not be determined. However, the most likely explanation is that the signals were not heard. The upper control station of the pleasure craft provided an all-round view, but the lower station was being used, notwithstanding the confines of the buoyed channel. The operator's ability to maintain a proper lookout from the lower control station was restricted visually by the fitted cupboards as well as the lowered blinds on the port side of his vessel's main cabin. Additionally, the noise generated by the twin gasoline engines would have hampered his ability to detect the whistle signals being sounded by the SpiritofVancouverIsland. It can be concluded that a proper lookout was not maintained aboard the StarRuby. The StarRuby was equipped with a VHF radio at the lower control station, but due to the design of this radio and the damage it sustained as a result of the collision, it could not be determined if the radio was on at the time of the accident or, if so, which channel was being monitored. Monitoring of MCTS Frequencies As a pleasure yacht that is less than 30 metres in length, the StarRuby was not required to, and did not participate in the Vessel Traffic Services (VTS) scheme controlled by Victoria MCTS. Few recreational boaters are in the habit of monitoring the VHF traffic channels. The current practice by some pleasure craft operators of not monitoring MCTS working frequencies deprives them of valuable navigational information, including traffic movement, on which sound navigational decisions can be based. Action by Both Vessels and Collision Prior to departure, the ferry's master was aware of the presence of pleasure craft in the vicinity, one of which was later identified to be the StarRuby. After the ferry's departure and while it was increasing speed, the StarRuby was initially to the starboard side of the channel, with the SpiritofVancouverIsland, on her port quarter, intending to overtake. As the speed of the ferry increased, the overtaking manoeuvre eventually culminated in the narrow, 460 m long section of the passage. Being an overtaking vessel, the ferry was required to keep clear of the StarRuby.6 Between departure and the time of collision, other than the two short blasts indicating an alteration of course to port, seven short and rapid blasts were sounded on the ferry's whistle threetimes to indicate that the ferry was in doubt about the pleasure craft's intention. Although StarRuby did not respond either by a sound signal or action to clear the channel and the subsequent action of that vessel resulted in it moving toward the path of the SpiritofVancouverIsland, the ferry's speed was neither reduced nor were the engines stopped or reversed in sufficient time to avert the collision.7 As the narrow channel was only 460 m long and given that the StarRuby was proceeding at a speed of around 9 knots, a reduction in speed by the ferry to permit the StarRuby to continue on and clear the channel would not have adversely affected her steerageway nor would it have had a significant impact on the schedule of the vessel by more than a few minutes. The safety of the ferry would not have been compromised by a reduction in speed to avoid an overtaking situation in the narrow section of the channel. Given the conditions under which the StarRuby engine controls and helm settings were found after salvage, objective conclusions as to positions of the controls just prior to the collision cannot be made. The StarRuby was a vessel of less than 20metres in length and, therefore, was required not to impede the safe passage of the ferry.8 Although the operator of the StarRuby was an experienced boater, he did not take action in response to the warning signal sounded repeatedly by the ferry. This would suggest that he was unaware of the presence of the ferry until it was too late to take effective collision-avoidance measures. As neither person aboard the StarRuby survived, it cannot be determined why the pleasure craft turned to port towards the bow of the SpiritofVancouverIsland when both vessels were travelling through this restricted portion of Colburne Passage. Crew Training - BCFC Following the collision, the crew of the SpiritofVancouverIsland successfully launched a rescue craft in approximately 3minutes, an indication that the ferry's crew was well trained and efficient in these respects. Once on scene, the crew of the rescue boat tried to do their best, but it was not until the arrival of the CCGC Skua, some 38minutes later, that proper co-ordination at the accident scene took place. This resulted in a delay in the recovery of the second person from the StarRuby. When a marine distress situation arises, BCFC vessels on their various routes along the B.C. coast are often in a position to provide the first response until the arrival of the Coast Guard. In the course of its 40-year history, the crews of BCFC vessels have discharged their legal and statutory obligations in response to distress situations on countless occasions. These responses have evolved without co-ordination and without cross-training between RCC, MCTS and the BCFC. Search and Rescue Although the SpiritofVancouverIsland was involved in a collision with a pleasure craft within the Victoria MCTS reporting system, the collision was not reported to MCTS9 by the ferry. The collision was reported to Victoria MCTS by a pleasure craft in the area on VHF channel16. About four minutes later, MCTS was advised by the SpiritofVancouverIsland that their rescue craft was launched. Further, communication between the ferry, her rescue boat, and MCTS/RCC was scanty and incomplete, which did not permit accurate evaluation of the situation by RCC. Additionally, radio traffic on VHF channel16 became very active post-accident. As a consequence, RCC was in receipt of conflicting information from various sources. This contributed to an initial confusion at both MCTS and RCC in their attempt to determine the position of the collision, the vessels involved and the number of persons at risk. Pleasure craft were on scene almost immediately and a rescue craft from the SpiritofVancouverIsland was launched and alongside the StarRuby without delay. Although the SpiritofVancouverIsland made every effort to assist the StarRuby, the master did not assume many of the responsibilities of Incident Commander, as prescribed in BCFC policy, to co-ordinate rescue efforts on scene. Upon arrival on scene, the commander of the CCGC Skua assumed the role of the On-Scene Co-ordinator (OSC), as assigned. This was some 42minutes after the collision. A Transfer of Command from the Incident Commander to the OSC10 did not take place. As a result, the OSC experienced difficulty in obtaining reliable information as to exactly what had transpired prior to his arrival. Without a single source of information, there was an abundance of sometimes conflicting information, all of which had to be either confirmed or re-confirmed. The absence of an interim OSC resulted in the loss of valuable time and resources essential to the success of a SAR mission. Navigating Near Pleasure Craft Compliance with the International Regulations for Preventing Collisions at Sea,1972, which prescribe safe practices for collision avoidance, helps ensure that all mariners operate their vessels in a safe manner with due regard for fellow mariners, whether they are operating commercial vessels or pleasure craft. Instances where the lack of professional courtesy and respect for fellow mariners have culminated in dangerous marine occurrences are on record. The need for commercial vessels and pleasure craft to operate in harmony has been recognized by Transport Canada. This is reflected in Ship Safety Bulletin No10/87, Safe Navigational Practices - Professional Courtesy and Respect for Fellow Mariners, which reads, in part: Mariners in charge of larger vessels must recognize that smaller vessels are generally more vulnerable to the effects of passing vessels and should take appropriate action to prevent endangering these smaller vessels. Mariners operating smaller vessels must not impede the safe passage of larger, less manoeuvrable vessels; it would be dangerous to assume that mariners in charge of larger vessels can always see, appreciate and avoid endangering a smaller vessel. Prior to departure, the bridge team brought to the attention of the master three pleasure craft that had the potential to interfere with the ferry's transit. The master acknowledged this information and the ferry sailed. Given that ferries often encounter large numbers of pleasure craft which sometimes pass at close range and that pleasure craft generally will keep out of the way of the ferries especially in restricted waterways, the master expected the StarRuby to do likewise. This would account for the master attempting to overtake the pleasure craft instead of taking the more cautious approach of proceeding at a safe distance astern of the pleasure craft until clear of the narrow section of the buoyed channel. Following this decision, the master's attention was focussed on navigating his vessel through the narrow channel to the detriment of traffic safety. First, the ferry's course was altered to port earlier than usual to give the pleasure craft more room. As the distance between the ferry and the pleasure craft was decreasing, seven short and rapid blasts were sounded on the ferry's whistle to indicate doubt as to the pleasure craft's intentions. The warning signals were sounded three times before the master took collision avoidance measures but the avoidance action was too late. On the other hand, the operator of the StarRuby should have been cognizant of the presence of the ferry traffic and the operational constraints placed on pleasure craft when navigating in Colburne Passage and in the vicinity of a ferry terminal. In the narrow channel, StarRuby was required by the Collision Regulations to keep to the starboard side of the channel, not to cross in front of the other vessel and, being under 20m, not to impede the passage of a vessel which can safely navigate only within a narrow channel. In any event, neither vessel followed the prescribed rules for collision avoidance, which are based on the principle of mutual respect and professional courtesy for fellow mariners. Factors Affecting Decision Making Ferries provide an essential service to the community and are widely used as a means of daily commute. In keeping with the BCFC mission statement/operating objectives, management has informed the ship's personnel on a continual basis that, while safety and on-time performance are essential elements, safety takes precedence over sailing schedules. Maintenance of B.C. Ferry Corporation published schedules is important to users of the service and creates formal and informal on-time performance criteria. Passengers and shore staff readily notice and comment on delays. This causes the ship's crew to establish and adhere to operational practices which have proven successful in maintaining expected performance levels. Therefore, when encountering situations which may not be within established norms, there may be a tendency to place importance on maintaining the schedule. Encountering pleasure vessels in Colburne Passage and other restricted areas is part of normal BCFC vessel operations. In this instance the SpiritofVancouverIsland's departure was essentially on time. When considered in conjunction with the underlying subtle pressure to maintain on-time performance, the master's mental model, that small vessels generally move out of the way when a ferry approaches or sounds its whistle, could account for the decision to overtake the pleasure craft in the narrow section of the channel to the exclusion of other, safer navigational options. Upon departure from the terminal, the SpiritofVancouverIsland increased speed and attempted to overtake the StarRuby within the narrow portion of Colburne Passage, thereby precipitating a close-quarters situation. The more cautious alternative, of proceeding at a safe distance astern of the pleasure craft until clear, was not taken. Although there were sufficient cues to warn both vessels that a risk of collision existed, the SpiritofVancouverIsland and the StarRuby entered the narrow section of the channel on converging courses. The StarRuby was apparently unaware of the presence of the SpiritofVancouverIsland and the situation was further aggravated by the pleasure craft not remaining to the starboard side of the channel. For reasons not known, the StarRuby turned to port towards the bow of the SpiritofVancouverIsland when some 40m separated the two vessels, resulting in contact between the port side of the pleasure craft and the starboard side of the ferry. The ability of the operator of the StarRuby to maintain a proper lookout was hampered by the presence of cupboards on the port side, the lowered blinds and the ambient shipboard noise. Neither the SpiritofVancouverIsland nor the StarRuby was operated in a professional and courteous manner, having due regard to the safety of other vessels.Findings as to Causes and Contributing Factors Upon departure from the terminal, the SpiritofVancouverIsland increased speed and attempted to overtake the StarRuby within the narrow portion of Colburne Passage, thereby precipitating a close-quarters situation. The more cautious alternative, of proceeding at a safe distance astern of the pleasure craft until clear, was not taken. Although there were sufficient cues to warn both vessels that a risk of collision existed, the SpiritofVancouverIsland and the StarRuby entered the narrow section of the channel on converging courses. The StarRuby was apparently unaware of the presence of the SpiritofVancouverIsland and the situation was further aggravated by the pleasure craft not remaining to the starboard side of the channel. For reasons not known, the StarRuby turned to port towards the bow of the SpiritofVancouverIsland when some 40m separated the two vessels, resulting in contact between the port side of the pleasure craft and the starboard side of the ferry. The ability of the operator of the StarRuby to maintain a proper lookout was hampered by the presence of cupboards on the port side, the lowered blinds and the ambient shipboard noise. Neither the SpiritofVancouverIsland nor the StarRuby was operated in a professional and courteous manner, having due regard to the safety of other vessels. The current practice by some pleasure craft operators of not monitoring the MCTS working frequency deprives them of valuable navigational information, including traffic movements, on which sound navigational decisions can be based. While operating in the vicinity of the ferry terminal, precautions were not taken by the StarRuby to safely transit the area. None of the charts aboard the StarRuby, (either U.S. or Canadian), paper or electronic, included ferry tracks in Colburne Passage.Findings as to Risks The current practice by some pleasure craft operators of not monitoring the MCTS working frequency deprives them of valuable navigational information, including traffic movements, on which sound navigational decisions can be based. While operating in the vicinity of the ferry terminal, precautions were not taken by the StarRuby to safely transit the area. None of the charts aboard the StarRuby, (either U.S. or Canadian), paper or electronic, included ferry tracks in Colburne Passage. Manoeuvring data for the SpiritofVancouverIsland compiled during sea trials was not posted on the bridge for ready reference. Speeds for the control settings were not compiled during sea trials. Communication between the ferry, her rescue boat and MCTS/RCC was minimal and incomplete, resulting in loss of valuable time in reconfirming information essential for the success of the SAR mission. While the crew of the rescue boat of the SpiritofVancouverIsland responded quickly, they had received little or no training in the recovery of survivors other than in man-overboard situations originating from their own vessel. There is no regulatory requirement for the training of commercial shipboard rescue boat crews in SAR situations. The ferry's master did not assume the role of Incident Commander or interim OSC, did not report the accident to the authorities in a timely manner, and communication with SAR authorities was minimal.Other Findings Manoeuvring data for the SpiritofVancouverIsland compiled during sea trials was not posted on the bridge for ready reference. Speeds for the control settings were not compiled during sea trials. Communication between the ferry, her rescue boat and MCTS/RCC was minimal and incomplete, resulting in loss of valuable time in reconfirming information essential for the success of the SAR mission. While the crew of the rescue boat of the SpiritofVancouverIsland responded quickly, they had received little or no training in the recovery of survivors other than in man-overboard situations originating from their own vessel. There is no regulatory requirement for the training of commercial shipboard rescue boat crews in SAR situations. The ferry's master did not assume the role of Incident Commander or interim OSC, did not report the accident to the authorities in a timely manner, and communication with SAR authorities was minimal. The Canadian Coast Guard, Office of Boating Safety, maintains a publication, Safe Boating Guide, which offers important information for pleasure craft operators. In the section headed Marine Communication and Traffic Services, which describes MCTS functions and services, the following phrase was added as a result of the occurrence: When recreational boaters operate in close proximity to larger commercial shipping, they can learn the intended movements of ships by passively monitoring the appropriate VTS sector frequency. The BCFC has initiated Bridge Resource Management training for their ferry officers and the master of SpiritofVancouverIsland participated. BCFC has established contact with the Canadian Coast Guard Pacific Region with a view to obtaining a small craft training program for BCFC crews in order to better prepare them for emergency response requirements.Safety Action Taken The Canadian Coast Guard, Office of Boating Safety, maintains a publication, Safe Boating Guide, which offers important information for pleasure craft operators. In the section headed Marine Communication and Traffic Services, which describes MCTS functions and services, the following phrase was added as a result of the occurrence: When recreational boaters operate in close proximity to larger commercial shipping, they can learn the intended movements of ships by passively monitoring the appropriate VTS sector frequency. The BCFC has initiated Bridge Resource Management training for their ferry officers and the master of SpiritofVancouverIsland participated. BCFC has established contact with the Canadian Coast Guard Pacific Region with a view to obtaining a small craft training program for BCFC crews in order to better prepare them for emergency response requirements. Safety Action Required Small Vessels Operating in Close Proximity to Ferries Passenger and vehicle ferries, navigating in narrow channels and in the vicinity of berths/terminals, are often restricted in their ability to manoeuvre simply because there is little room to do so. Furthermore, the handling characteristics of these vessels are such that it takes a longer time to reduce speed and stop. Many ferries may proceed at speeds comparable to or greater than that of small vessels. Operators of small vessels, therefore, need to be vigilant and avoid situations which may impede the passage of such ferries. General information about ferry routes and berths is contained in charts (including electronic charts) and publications. Use of this information helps to ensure a safe voyage. Furthermore, the Charts and Nautical Publications Regulations, 1995, require vessels to carry charts and publications on board in respect of the area in which the vessel is being navigated. The Sailing Directions, British Columbia Coast (South Portion)11, for example, describes where ferries operate to and from and that a ferry could be encountered anywhere along the charted route. The publication gives a general direction of the ferry route. Though most Canadian charts in use indicate ferry routes, there are some charts, including those carried aboard the StarRuby, that do not. Also, while the route of the Washington State ferry was indicated on the rudimentary map of the Strait of Georgia, displayed on the GPS handheld used aboard the StarRuby, it did not indicate the routes of BCFC. Consequently, the lack of information about local ferry routes, routines, and practices may continue to put operators who are unfamiliar with the area in which they are navigating at risk. Collision and close-quarters situations between ferries and small vessels in narrow channels and in the vicinity of ferry berths are not uncommon and have been reported in waterways across Canada. Since1990, there have been 12collisions, resulting in two deaths (from this occurrence), and 118close-quarters situations in Canadian waters involving ferries reported to the TSB (seetables1and2). Of the 12collisions, 8were considered to have occurred in the vicinity of ferry berths and two in narrow waterways. Recreational-type craft were involved in five of the occurrences, the rest involved a variety of vessel types. Table1. Collisions reported to TSB involving ferries since 1990. Table2. Close-quarters situations reported to TSB involving ferries since 1990. Of the 118 close-quarters situations, 82 occurred in British Columbia. Of the remaining 36 close-quarters situations in the rest of the country, 15 were considered to be in the vicinity of ferry berths and in restricted waterways. Fishing vessels accounted for most of the close-quarters situations on the east coast, while in British Columbia, recreational-type craft, fishing vessels and others (e.g., tugs, water taxis, seaplanes, barges, large bulk carriers) each accounted for approximately one-third. There is anecdotal evidence to suggest that the number of close-quarters situations reported to the TSB under-represents the actual number which occur in Canadian waters. Operators of vessels involved in close-quarters situations tend to consider them as 'one-time' events and accept them as being 'hazards of the trade' and thus not reportable. Because of the large number of close-quarters situations reported in British Columbia, five geographic areas were examined in further detail (seeTable3). Four of the areas were in the vicinity of ferry berths, namely: Tsawwassen; Swartz Bay; Horseshoe Bay; and, Departure Bay. The fifth area was Active Pass, a narrow channel east of Vancouver Island through which ferries commonly navigate. These areas accounted for approximately 37 per cent of the close-quarters situations. Table3. Close-quarters situations reported in British Columbia by selected area. The International Regulations for Preventing Collisions at Sea, 1972, require vessels to keep clear of each other. Small vessels are not to impede the passage of large vessels which can safely navigate only in a narrow channel or are constrained by their draught. Small vessel operators, including operators of foreign vessels, who may be unaware of local ferry routes, routines and practices, and the dangers of operating in close proximity to ferries, will continue to be at risk. Given that some Canadian and US charts and publications do not indicate ferry routes or contain information about ferry routines and practices, the Board is concerned that the risks associated with the identified deficiency will continue to compromise the safety of small vessels operating in the vicinity of ferry terminals and in restricted waterways.